Joshua I. Greenberg1, Kristin Alix1, Mark Nehler1, Robert Johnston2, Charles Brantigan1
1Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO; 2Diversified Radiology, Denver, CO.
OBJECTIVES: Failure after surgical treatment for neurogenic thoracic outlet syndrome (nTOS) is a frustrating problem for both patients and physicians. Fortunately, many patients with unresolved or recurrent symptoms demonstrate a mechanical etiology at operation owing to inadequate previous rib resection, rib regrowth, or scar tissue formation. The purpose of this study is to evaluate the utility of multidetector computed tomography (CT) in predicting surgical outcomes in patients with recurrent nTOS.
METHODS: A retrospective chart-review was performed of a TOS referral practice from 2003-2012. In 2003, a dedicated TOS CT protocol was established to assist in clinical decision making and operative planning. Imaging as well as patient clinical characteristics, interventions, and outcomes were reviewed.
RESULTS: Two hundred eighteen TOS operations were performed on 139 patients. These included 20 reoperations for neurogenic symptoms. Mean time to failure of primary surgery was 26.6 months; mean follow-up after reoperation was 43.3 months. Sixty percent of redo cases were in females; mean age was 34.8 years. Sixteen procedures involved transaxillary rib resections with brachial plexus neurolysis (80%). Only 5 (25%) cases involved inadequate previous rib resections; the remainder for scar tissue (50%) and/or rib regrowth (40%). There were no neurovascular injuries or complications other than pneumothorax associated with planned pleurectomy in 10 cases (50%). Nine patients (45%) demonstrated significant improvement or resolution of symptoms, seven patients (35%) received moderate improvement in symptoms, and four patients (20%) showed minimal improvement. Positive-predictive value for the use of CT in predicting a good surgical outcome was 92.3%.
CONCLUSIONS: Recurrent thoracic outlet syndrome is an often vexing problem with challenging solutions. These results demonstrate the utility of a TOS protocol CT scan for patient selection and operative planning.
AUTHOR DISCLOSURES: K. Alix: Nothing to disclose; C. Brantigan: Nothing to disclose; J. I. Greenberg: Nothing to disclose; R. Johnston: Nothing to disclose; M. Nehler: Nothing to disclose.
Posted April 2013